A barely dressed seductress draped across the hood of a car. A seductor with piercing eyes holding a diamond watch. A girl-next-door with a new shampoo. A MILF savoring a once-frozen entrée.

Madison Avenue’s “Mad men” work round the clock to sell us stuff we don’t really need and may even regret by the time the bill comes—often by packaging it with sex. When we think of saints and superheroes, advertisers aren’t exactly top of mind. But in a crisis like the Zika pandemic, Mad men (and Mad women) may have the power to save thousands of families from lifelong suffering precisely because they’re so practiced at getting our attention and selling stuff they associate, in just the right way, with sex.

Libertarian entrepreneur Phil Harvey is a pioneer of social marketing—not social media but the application of Madison Avenue’s skill set and commercial infrastructure to solve social problems by selling needed goods at subsidized rates through ordinary retail channels.

Harvey has spent much of his life focused on the problem of badly timed or unwanted pregnancy. He got his start trying to reduce hunger in rural India and realizing that the number of hungry children kept growing unless parents had means to manage their fertility. If the solution was going to be “more permanent and more real,” it needed to include family planning, and couples needed to know their options. He pivoted. Forty years later he is board chair and former CEO of DKT International, one of two nonprofits that he founded. DKT has sold tens of millions of condoms around the world, preventing HIV and unwanted pregnancy by making safe sex hot.

Harvey spoke with me from his Washington D.C. home about Zika and how marketers might make a difference.

Tarico: Latin Americans are panicking. Governments have told women to delay pregnancy until the Zika pandemic has either swept through or been brought under control. But that’s not exactly helpful for women who may lack the power to refuse sex or otherwise prevent pregnancy. So, delaying pregnancies is going to involve men and modern contraceptives. How do we make that happen?

Harvey: Social marketing of contraceptives rests on mass media advertising and ubiquitous point of purchase. That means getting appealing, branded products at affordable prices into every little store and kiosk in which fast moving consumer goods are normally available. We’ve been doing that for 20 years in Brazil with an enormous variety of condoms –flavors, colors, aromas. Those products might be available in 40,000 or 50,000 different outlets.

Social marketing can drive demand for products like these or it can promote pro-social ideas and behavior change—for example like advertising against smoking.

Tarico: I like to tell myself that advertising doesn’t really affect me. But I have to believe that the market isn’t stupid, at least in the narrow sense of companies knowing what affects sales and profits. When it comes to social marketing, how do you measure what works?

Harvey: Ads generally bring about increases, but it’s hard to know which of TV spots or a big musical event or a series of magazine ads (all things we are doing in Latin America) —made the difference. People in the industry like to say, “We know that at least half of ad budget is wasted, we just don’t know which half.” We do know for sure that advertising works. We spent 20 million on pure advertising last year. In some countries a half million dollars goes a long way.

Tarico: So what is your reach in the Zika plague areas?

Harvey: In Brazil in 2015 we sold 110 million condoms through our proprietary branded products, Prudence and a dozen others. The commercial market would be 2 ½-3 times that. The government is also giving away condoms. In 2014, the Brazilian market was almost a billion condoms. Half was government giveaways.

Tarico: If the government is giving away condoms, why the need for social marketing? Also, don’t giveaways erode the market in the long run by interrupting demand and sales or making it impossible for businesses to compete with free products?

Harvey: At times government giveaways can actually increase the commercial market by stimulating interest in a product. For example, when the Brazilian government was promoting condoms for HIV/AIDS they did interesting sexy advertising; and that stimulated the commercial market. At other times it can become competitive. In Brazil, DKT competes more with commercial brands, because government condoms tend to be thought of as inferior because they are not well packaged. But even with both government and profit-driven companies in the game, social marketing still improves lives. By increasing competition, we drive down the price as well as driving up availability of appealing products.

Tarico: How about other contraceptives? Condoms are a heck of a lot better than nothing, but they require diligence and mutuality, which is why they have a 1 in 6 annual pregnancy rate. By contrast, “get it and forget it” IUDs and implants drop the pregnancy rate below 1 in 500. They don’t take constant vigilance and don’t fail just because people are tired or drunk or make a mistake. They put females in charge of our own fertility and have some bonus health benefits. As a mom of two daughters that combination makes me a big fan.

Harvey: DKT Brazil does just condoms, not pills or long acting methods. But pills are available in every drug store. In El Salvador, PSI has a program for IUDs. But IUDs are expensive, as is insertion. So the most simple and immediate and cost effective way to improve lives is one of several brands of condoms. PSI social marketing sold 2.5 m condoms in 2014. A good many IUDs were also sold in 2014. One of the things that the Salvadorian government could do is get on mass media and tell people about the availability of good contraceptives and where to get them.

Tarico: In some traditional cultures, men see a woman’s pregnancy—or lots of offspring–an indicator of their own virility and status. If we have to rely on men to prevent an epidemic of babies is that going to work?

Harvey: The total fertility rate in Latin America is just over two children per woman, by contrast with almost six in 1960. It’s reasonable to assume that men as well as women are taking part in the decisions that have led to low fertility. Seventy-five percent of all couples in Brazil are using some modern method of birth control.

Tarico: Condoms can be 98 percent effective if used perfectly and with perfect consistency. But humans aren’t perfect, which is why we get such a high pregnancy rate—from human inconsistency and error. If you were creating a marketing campaign aimed at men, to get them to be even more careful right now, how would you go at that?

Harvey: My best guess would be to focus on the message that getting your wife or girlfriend pregnant right now could lead to serious problems. I don’t think men want to sire defective babies. It shouldn’t be too hard to remind them that they can prevent that. I think that would be powerful but I would want to try it out. I would conduct focus groups, mindful that we are messaging in a new context.

Tarico: Even here in the U.S, where 98 percent of sexually experienced females have used a modern contraceptive at some point, and with a birthrate just above replacement, half of pregnancies are not intentional, and I understand that the rate is even higher in Latin America. That seems like a lot of potential for babies microcephalic, brain damaged babies.

Harvey: Well, a very substantial are not intended at the time they occur, but that doesn’t necessarily represent a contraceptive failure in people who really don’t want to get pregnant. A lot of young women in poor communities absolutely want to become mothers, and aren’t as focused on when. They’re ambivalent or unsure or indifferent about getting pregnant sooner rather than later. If I were a woman in Brazil, I would be moving from I don’t know to I really don’t want to get pregnant right now. The idea of a baby with birth defects is well understood and devastating. In the U.S. it’s a minor risk right now, but that could change.

Tarico: Will DKT be shifting priorities in response to Zika?

Harvey: Carnival is just beginning in Rio, and DKT Brazil will be giving out 300,000 condoms over the course of the week. In keeping with the spirit of Carnival, they will include Fire, a warming condom, Ice, which tingles, and Neon, which glows in the dark. The United Nations has called for greater contraceptive access as part of the Zika emergency response, and we are preparing to distribute an extra 200,000 condoms as part of the effort. The Brazil team, led by our Country Director Daniel Marun, is filming 3-minute videos on Zika prevention featuring a popular sexual health educator, Dr. Jairo Bouer. You’ll be able to find them on our YouTube channel.

Tarico: Thank you for taking time for this conversation—and for all of the wellbeing you have brought into the world during the last forty years! Readers are probably ready to check out your sexy commercials. I noticed that one has over 6 million clicks! But any final comment?

Harvey: The Zika virus is a new ball game. The business that we have been in for the last 40 years is “If you don’t want to get pregnant, here’s how” or “Did you know it’s possible to only get pregnant if you want to – to space or limit your children.” We’ve worked where a majority of women didn’t even know it was possible to have sex without getting pregnant and in societies where women knew about contraceptives but didn’t have access. This situation calls for a very different social marketing approach. It’s tricky business for government to say don’t get pregnant right now because that carries a lot of freight. So what’s important is getting the facts out there so that people can make up their own minds. Parenthood is the center of life for a lot of young women in poor communities, so you have to address young women on doing it for their kids. So you have to talk about it as parenting from the beginning, from even before a baby is conceived. This is a new game.

I read in the UK press here that the very influential Catholic church in Brazil isn’t going to reverse its ban on contraception any time soon. My heart goes out to poverty-stricken couples particularly who are told to go ahead and conceive, all part of ‘god’s plan’ for you to have a severely handicapped child with hardly any medical or financial resources to meet her/his needs for many years to come..

Valerie – Just before reading this post, I saw the following:http://www.moonofalabama.org/2016/02/the-zika-virus-is-harmless-why-then-this-media-panic.html
Nobody seems to be reporting the truth about the Zika virus in terms of the known scientific facts about the virus and its effects, and the difficulties in connecting a reported, but undocumented, increase in microencephaly diagnoses to any particular cause. There is evidence that the number of actual cases of microencephaly is far less than reported and the number of those cases that can be correlated with the mother having had the Zika virus is very small (and we know correlation is not causation).
Encouraging contraceptive use is generally a good thing as it promotes healthy lives, healthy, planned families, etc. However, there is something weird going on with all the media bluster about a pandemic of microencephaly that, as of yet, is not supported by empirical evidence.
As b says in the linked article, Cui Bono?

Hi John –
While I might expect the press to hype a pandemic, the same isn’t true for the UN or CDC or the various academic epidemiologists and virologists who are raising concerns and issuing recommendations.

My “b.s. alarm” was ringing loudly after visiting the “moonofalabama” website, so I decided to do a little checking. The incidence of microcephaly (U.K.) is 1.02 per 10,000 live births. At the time, these numbers were derived, US births were slightly less than 4 million, so it was estimated (using the U.K. data) that 407 infants per year would be born with microcephaly in the US. Last year, the US had 4,471,274 live births, so the expected number of US infants born with microcephaly in 2015 would have been 456. Obviously, this is a long way from the 25,000 reported by moonofalabama!

Projecting the (U.K.) incidence of microcephaly to Brazil, of 3,655,906 live births last year, 373 births with microcephaly would have been expected. The actual number born with microcephaly (8000) represents a large increase, so there’s obviously a problem in Brazil!

Lowell – Not to dispute your statistics, but the 25,000 figure was from an article published on the journal Neurology cited at John Rappoport’s blog: “Practice Parameter: Evaluation of the child with microencephaly (an evidence-based review)”; Neurology 2009 Sep 15; 73(11) 887-897; Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. http://www.ncbi.nlm.nih.gov/pubmed/19752457

Moon of Alabama does not generally make things up, but instead documents his quotes rather extensively. However, I don’t rule out that academic papers may have an agenda.

Also, please consider, since that the health care systems of the UK and the US are very different and in the US we do not prioritize getting ALL expectant mothers into good pre-natal care, there may be significant differences in the incidence rate of microencephaly between the UK and US.

Valerie – While I am not as sanguine about the integrity of the CDC and the UN as you are (and even less so as to academic researchers who frequently have serious conflicts of interest), the fact remains that almost all of the articles about the Zika virus admit that the connection between the virus and microcephaly is unknown. (I just realized I have been spelling it wrong.)

Also, considering the Brazilian Health Ministry’s report that only 36.9% the microcephaly diagnoses that were more carefully examined were actually micorcephaly and not some other issue such as small but normal brain sizes, and that only 6 of those actual cases of microcephaly had the Zika virus, perhaps the incidence of Zika-caused microcephaly is significantly less than feared.

And this, “Brazilian officials still say they believe there’s a sharp increase…of microcephaly and strongly suspect the Zika virus,… is to blame.” Once again “believe” and “suspect”.

The Zika virus was identified in 1947, and since that time there has been no indication of it causing serious fetal damage: “There is no known physiological basis for how Zika virus can cause microcephaly, and previous epidemics do not help make the case. A 2007 outbreak on Yap Islands in Micronesia is estimated to have affected nearly 75% of the population of some 12,000 people, and a 2013 outbreak in French Polynesia affected nearly 28,000 of 270,000 residents. Neither epidemics caused a spike in microcephaly.” — http://qz.com/585140/a-virus-linked-to-shrinking-newborns-brains-is-spreading-rapidly-beyond-brazil/

Why? Why now? I realize that at least one researcher has put forth the idea that there is a new, more virulent mutation of the Zika virus, but that is still just speculation.

Perhaps I was too quick to label the information presented in the Moon of Alabama post as “Truth”, but the fact remains that we simply do not know if the Zika virus causes microcephaly.

Thank you, Lowell. John — Experts from the University of Washington are saying that not only does it appear that something is going on with Zika, but that the brain damage is far worse than with typical Microcephaly.

Well. After reading J. Zelnicker’s comment, (just ahead of me, on my screen here), I read through the “moonofalabama.org” link. I doubt that I’ll visit there again. More feather-light weight chatter blowing in the wind? I didn’t find empirical evidence. Rather, repetitive, off-the-top, un-sourced assertions. I too have my concerns over the ease with which simple and perhaps paranoid ideas take root widely in the public discourse. And I agree that the “News and Entertainment Media” play a big part. So, it seems to me that my personal responsibility is to “study” more. Learning what’s “real; true; actionable” calls for more effort (on all our part’s). Less attention to the shallowest of the media; more to the deeper, and documented. Good, Valerie.

Do you consider the Brazilian Health Ministry, the Congressional Research Service and a committee of the American Academy of Neurology to be light weight? These are the sources for the assertions at Moon of Alabama.

In the article you cite, microcephaly is defined a having a head circumference 2 standard deviations below the mean. Assuming a normal distribution, 2.28% of the population, or 1 in 44, would have this condition. However, the actual incidence is 0.54-0.56%, or roughly 1 in 180. Given that number, 24,840 babies would have been born with microcephaly last year.

That said, there are several issues:

(1) According to the article, “Microcephaly is an important neurologic sign but there is nonuniformity in the definition of microcephaly and inconsistency in the evaluation of affected children. Microcephaly is usually defined as a head circumference (HC) more than 2 SDs below the mean for age and gender. Some academics have advocated for defining severe microcephaly as an HC more than 3 SDs below the mean.”

(2) According to the article, “There are conflicting data as to whether proportionate microcephaly (i.e., similar weight, height, and head size percentiles) is predictive of developmental and learning disabilities.” Individuals with microcephaly have higher rates of epilepsy and cereberal palsy. Individuals with mild microencephaly (2-3 standard deviations below the mean) are about 5 times as likely to be developmentally disabled as the general population (11% vs. 2.28%), but the remaining 89% would fall into the “normal” category. 51% of individuals with severe microcephaly (more than 3 standard deviations below the mean) are likely to developmentally disabled, but the remaining 49% would fall into the “normal” category.

Clearly, microcephaly per se, defined as nothing more than having a small head, doesn’t describe major public health issue facing the world today.

An online medical dictionary gives 11 different types of microcephaly, and the article you cite states that microcephaly may be caused by 25 different genetic anomalies, as well as external factors.

I suspect, although I’m not sure, (and I’m not going to pay $35 to find out. :)) that the specific variety of concern to public health authorities is Microcephaly vera, a variety that is quite rare. (Perhaps there’s someone more knowledgeable here that can explain it better. :))

One thing is clear, however: The “moonofalabama” website made a false comparison between a condition that is relatively common, but often innocuous, and a condition that is rare, but that can have severe consequences!